Hospital padrino: a collaborative strategy model to tackle maternal mortality: a mixed methods study in a middle-income region

Background

Reducing maternal mortality ratio (MMR) remains a paramount goal for low- and middle-income countries (LMICs), especially after COVID-19's devastating impact on maternal health indicators. We describe our experience implementing the Hospital Padrino Strategy (HPS), a collaborative model between a high-complexity hospital (Fundación Valle del Lili) and 43 medium- and low-complexity hospitals in one Colombian department (an administrative and territorial division) from 2021 to 2022, to sustain the trend towards reducing MMR. The study aimed to assess the effects of implementing HPS on both hospital performance and maternal health indicators in Valle del Cauca department (VCD).

Methods

A mixed-methods study was conducted, comprising two phases. In the first phase, we investigated a cohort of hospitals through prospective follow-up to assess the outcomes of HPS implementation on hospital performance and maternal health indicators in VCD. In the second phase, qualitative data were collected through focus groups with 131 health workers from 33 hospitals to explore the implications of the HPS implementation on healthcare personnel. All data were obtained from records within the HPS implementation and from the Health Secretary of VCD.

Findings

Evidence shows that in the context of HPS, 51 workshops involved 980 healthcare workers, covering the entire territory. Substantial improvements were observed in hospital conditions and healthcare personnel's technical competencies when providing obstetric care. Seven hundred eighty-five pregnant women with obstetric or perinatal emergencies received care through telehealth systems, with a progressive increase in technology adoption. Nine percent required Intensive Care Unit (ICU) admission, and none died. The MMR decreased from 78.8 in 2021 to 12.0 cases per 100,000 live births by 2022. Improvements in indicators and conducted training sessions instilled confidence and empowerment among the healthcare teams in the sponsored hospitals, as evidenced in focus groups derived from a sample of 131 healthcare workers from 33 hospitals.

Interpretation

Implementing the Hospital Padrino Strategy led to a significant MMR reduction, and consolidated a model of social healthcare innovation replicable in LMICs.

Funding

The Hospital Padrino Strategy was funded by the Fundación Valle del Lili and the Health Secretary of Valle del Cauca. Furthermore, this study received funding from a general grant for research from Tecnoquimicas S.A.

Knowledge, attitudes, and perceptions of health care providers regarding the recommendation and use of long-acting reversible contraceptive devices for adolescent patients

OBJECTIVE

To describe the knowledge, attitudes, and perceptions of healthcare providers in a region in southwestern Colombia regarding the recommendation and use of long-acting reversible contraceptive (LARC) methods for adolescents.

STUDY DESIGN

This was a cross-sectional study. An online exploratory survey was designed to assess healthcare providers' knowledge, attitudes, and perceptions of Valle del Cauca hospitals. For the development of this the questionnaire, a literature search and validation of the instrument's appearance were conducted.

RESULTS

The survey was completed by 115 people. Knowledge: 62.6% and 33% of the participants did not consider themselves capable of correctly placing an intrauterine device (IUD) or a subdermal implant, respectively. However, 73.9% of the participants had adequate theoretical knowledge. Attitudes: 64.3% of the participants considered that adolescents can acquire contraceptive methods without limitations. Short-acting reversible methods were the least recommended. Perceptions: For IUDs, 40.8% and 16.5% of the participants imposed a minimum age and minimum parity requirement for their use, respectively. Side effects were the main reason for not recommending in health institutions with a lower level of complexity.

CONCLUSION

Healthcare providers had positive attitudes and adequate theoretical knowledge concerning to the effectiveness of LARCs. The main areas for improvement were practical knowledge about the insertion and proper use of the devices, indications for referral to gynaecologists for the insertion procedure, and concerns about side effects.

Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis

OBJECTIVE

Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy.

METHODS

Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension.

RESULTS

Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome.

CONCLUSION

Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.

Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America

OBJECTIVE

To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country.

METHODS

Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period.

RESULTS

We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00).

CONCLUSION

The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.

Impacts of childbirth on anxiety, disability, and depression: Results from a Brazilian cohort

Conditions such as violence, drug abuse, sexual satisfaction, anxiety, depression, and disability interfere with a healthy pregnancy and can also account for maternal morbidity. The instrument WOICE was built by WHO to measure it. We applied WOICE in a prospective cohort of 125 pregnant women, using a before-after approach, during the third trimester of pregnancy, and after 42 until 90 days of childbirth. 60% had anxiety during pregnancy, decreasing to 48.8% after delivery (p = 0.07), and depression scores decreased from 7.56 to 5.80 (p = 0.014). Disability affected 62.4% and 56, respectively. 9.6% used drugs during pregnancy, reducing to 4.0% after delivery (RR 0.69, IC 0.49 - 0.69).

Telemedicine consultation for emergency patients' attention: a clinical experience from a high complex university hospital from Latin America

INTRODUCTION

As a result of the new coronavirus pandemic, a highly complex academic hospital in Latin America implemented a telemedicine service for the care of obstetric, pediatric, and adult patients. In 2020, regional emergency services collapsed due to the increase in demand for care, generating the need to open expansion services and seek strategies to provide timely care to consulting patients.

OBJECTIVE

We retrospectively describe the clinical experience of patients who consulted the emergency department via telemedicine across a videoconference tool using digital platforms.

METHODS

A descriptive study with retrospective data collection was conducted to describe the implementation of the teleconsultation care model for patients. We constructed the clinical process indicators to evaluate the model.

RESULTS

A total of 4652 teleconsultations were registered. Telemedicine consultation was above 50% in the country and department and above 90% in Cali city. The average waiting time for care was estimated to be 1:59:52 h. A total of 275 patients were transferred to the emergency room after consultation. The principal reasons for consultation in the institutional telemedicine program were respiratory and gastrointestinal symptoms. Teleconsultations related to SARS-COV 2 infections reported 3775 patients (3127 with unidentified virus and 648 with the identified virus).

CONCLUSIONS

Telemedicine is a tool that provides support and guidance to patients who consult emergency departments, reducing barriers to access health care and decreasing emergency department collapse.

Clinical Experience of Using Telemedicine for the Management of Patients Using Continuous Subcutaneous Insulin Infusion in a Highly Complex Latin American Hospital

INTRODUCTION

Continuous subcutaneous insulin infusion (CSII) has emerged as a potential solution for diabetes management during the pandemic, as it reduces the need for in-person visits and allows for remote monitoring of patients. Telemedicine has also become increasingly important in the management of diabetes during the pandemic, as it allows healthcare providers to provide remote consultations and support. Here, we discuss the implications of this approach for diabetes management beyond the pandemic, including the potential for increased access to care and improved patient outcomes.

METHODS

We performed a longitudinal observational study between 1 March 2020 and 31 December 2020 to evaluate glycemic parameters in diabetic patients with CSII in a telehealth service. Glycemic parameters were time in range (TIR), time above range, time below range, mean daily glucose, glucose management indicator (GMI), and glycemic variability control.

RESULTS

A total of 36 patients were included in the study, with 29 having type 1 diabetes and 6 having type 2 diabetes. The study found that the proportion of patients achieving target glucose variability and GMI remained unchanged during follow-up. However, in patients with type 2 diabetes, the time in target range increased from 70% to 80%, and the time in hyperglycemia decreased from 2% to 0%.

CONCLUSIONS

The results of this study suggest that telemedicine is a strategy for maintaining glycemic control in patients using CSII. However, the lack of access to the internet and adequate telemonitoring devices make it difficult to use on a large scale in emerging countries like ours.

Pregnancy-specific responses to COVID-19 revealed by high-throughput proteomics of human plasma

BACKGROUND

Pregnant women are at greater risk of adverse outcomes, including mortality, as well as obstetrical complications resulting from COVID-19. However, pregnancy-specific changes that underlie such worsened outcomes remain unclear.

METHODS

Plasma samples were collected from pregnant women and non-pregnant individuals (male and female) with (n = 72 pregnant, 52 non-pregnant) and without (n = 29 pregnant, 41 non-pregnant) COVID-19. COVID-19 patients were grouped as asymptomatic, mild, moderate, severe, or critically ill according to NIH classifications. Proteomic profiling of 7,288 analytes corresponding to 6,596 unique protein targets was performed using the SOMAmer platform.

RESULTS

Herein, we profile the plasma proteome of pregnant and non-pregnant COVID-19 patients and controls and show alterations that display a dose-response relationship with disease severity; yet, such proteomic perturbations are dampened during pregnancy. In both pregnant and non-pregnant state, the proteome response induced by COVID-19 shows enrichment of mediators implicated in cytokine storm, endothelial dysfunction, and angiogenesis. Shared and pregnancy-specific proteomic changes are identified: pregnant women display a tailored response that may protect the conceptus from heightened inflammation, while non-pregnant individuals display a stronger response to repel infection. Furthermore, the plasma proteome can accurately identify COVID-19 patients, even when asymptomatic or with mild symptoms.

CONCLUSION

This study represents the most comprehensive characterization of the plasma proteome of pregnant and non-pregnant COVID-19 patients. Our findings emphasize the distinct immune modulation between the non-pregnant and pregnant states, providing insight into the pathogenesis of COVID-19 as well as a potential explanation for the more severe outcomes observed in pregnant women.

Telemedicine for the management of diabetic patients in a high-complexity Latin American hospital

BACKGROUND

Noncommunicable diseases such as diabetes mellitus (DM) have gained attention worldwide. Latin America experienced a rise in rates of DM. During the COVID-19 pandemic, a telemedicine program was implemented in a quaternary care academic complex in Latin America to continue the follow-up of patients with diabetes.

OBJECTIVE

The aim of this study is to describe the clinical experience of DM patient management through telemedicine and the HbA1c behavior of patients followed-up through this modality.

MATERIALS AND METHODS

We conducted a retrospective cohort study including all patients with type 1 or 2 diabetes who were treated via telemedicine from March to December 2020. A Wilcoxon statistical test was used to compare the changes in glycosylated hemoglobin between the first teleconsultation and after 6 months of telemedicine follow-up.

RESULTS

A total of 663 patients were included, 17.65% (117) of whom had type 1 diabetes and 82.35% (546) of whom had type 2 diabetes. Patients with both types of diabetes, presented with stable HbA1c values regardless of the length of follow-up.

CONCLUSION

The use of telemedicine can be a helpful tool for both patients and health care providers to support the continuity of care to maintain acceptable control levels within glycemic control goals.

Clinical outcomes in patients with solid tumors living in rural and urban areas followed via telemedicine: experience in a highly complex latin american hospital

BACKGROUND

Difficulties in cancer services access increase the burden of disease and mortality in rural areas, and telehealth can be a useful tool to address these inequalities.

OBJECTIVE

We aimed to describe the outcomes of patients in rural and urban areas with solid tumors managed by oncologists through telemedicine.

METHODS

We conducted a retrospective cohort study of patients with solid tumors from March to December 2020. A total of 1270 subjects with solid tumors were included, 704 living in urban areas and 566 in rural areas.

RESULTS

The most frequent tumors were breast (51.8%) and prostate (12.4%). The trend of telemedicine care was similar for both populations; in-person care was more frequent in the urban population. There were no differences in referral to the emergency room, need for hospitalization, and mortality for both groups.

CONCLUSION

Telemedicine is a care modality that reduces barriers in the care of patients with solid tumors, evidencing similar outcomes regardless of living in rural or urban areas.

Maternal and perinatal outcomes in mixed antenatal care modality implementing telemedicine in the southwestern region of Colombia during the COVID-19 pandemic

INTRODUCTION

Contingency measures due to the COVID-19 pandemic limited access to routine prenatal care for pregnant women, increasing the risk of pregnancy complications due to poor prenatal follow-up, especially in those patients at high obstetric risk. This prompted the implementation and adaptation of telemedicine.

OBJECTIVE

We aim to evaluate the maternal and perinatal outcomes of patients who received prenatal care in-person and by telemedicine.

METHODS

We conducted a retrospective observational cohort study of pregnant women who received exclusive in-person and alternate (telemedicine and in-person) care from March to December 20,202, determining each group's maternal and neonatal outcomes.

RESULTS

A total of 1078 patients were included, 156 in the mixed group and 922 in the in-person group. The patients in the mixed group had a higher number of prenatal controls (8 (6-9) vs 6 (4-8) p < 0.001), with an earlier gestational age at onset (7.1 (6-8.5) vs 9.3 (6.6-20.3), p < 0.001), however, they required a longer hospital stay (26 (16,67%) vs 86 (9,33%), p = 0.002) compared to those attended in-person; there were no significant differences in the development of obstetric emergencies, maternal death or neonatal complications.

DISCUSSION

Incorporating telemedicine mixed with in-person care could be considered as an alternative for antenatal follow-up of pregnant women in low- and middle-income countries with barriers to timely and quality health care access.

Effect of a model based on education and teleassistance for the management of obstetric emergencies in 10 rural populations from Colombia

Introduction

Pregnant women and health providers in rural areas of low-income and middle-income countries face multiple problems concerning high-quality obstetric care. This study was performed to identify changes in maternal and perinatal indicators after implementing a model based on education and telecare between a high-complexity hospital in 10 low-complexity hospitals in a southwestern region of Colombia.

Methods

A quasiexperimental study with a historic control group and without a pretest was conducted between 2017 and 2019 to make comparisons before and after obstetric emergency care through the use of teleassistance from 10 primary care centers to the referral center (Fundación Valle del Lili, FVL).

Results

A total of 470 patients were treated before teleassistance implementation and 154 patients were treated after teleassistance implementation. After program implementation, the maternal clinical indicators showed a 65% reduction in the number of obstetric patients who were referred with obstetric emergencies. The severity of maternal disease that was measured at the time of admission to level IV through the Modified Early Obstetric Warning System score was observed to decrease.

Conclusion

The implementation of a model based on education and teleassistance between low-complexity hospitals and tertiary care centers generated changes in indicators that reflect greater access to rural areas, lower morbidity at the time of admission, and a decrease in the total number of emergency events.

Pregnancy-specific responses to COVID-19 are revealed by high-throughput proteomics of human plasma

Pregnant women are at greater risk of adverse outcomes, including mortality, as well as obstetrical complications resulting from COVID-19. However, pregnancy-specific changes that underlie such worsened outcomes remain unclear. Herein, we profiled the plasma proteome of pregnant and non-pregnant COVID-19 patients and controls and showed alterations that display a dose-response relationship with disease severity; yet, such proteomic perturbations are dampened during pregnancy. In both pregnant and non-pregnant state, the proteome response induced by COVID-19 showed enrichment of mediators implicated in cytokine storm, endothelial dysfunction, and angiogenesis. Shared and pregnancy-specific proteomic changes were identified: pregnant women display a tailored response that may protect the conceptus from heightened inflammation, while non-pregnant individuals display a stronger response to repel infection. Furthermore, the plasma proteome can accurately identify COVID-19 patients, even when asymptomatic or with mild symptoms. This study represents the most comprehensive characterization of the plasma proteome of pregnant and non-pregnant COVID-19 patients.

Experience of a telehealth and education program with maternal and perinatal outcomes in a low-resource region in Colombia

INTRODUCTION

Maternal morbidity and mortality rates associated with perinatal care remain a significant public health concern. Rural populations from low and middle-income countries have multiple barriers to access that contribute to a lack of adherence to prenatal care, and high rates of maternal mortality and morbidity. An intervention model based on telehealth and education was implemented between a tertiary high complex care hospital and a second-level hospital from a limited source region.

OBJECTIVES

We sought to identify an association in maternal and perinatal care quality indicators after implementing a model based on telehealth and education for patients with obstetric emergencies between two hospitals in a southwestern region of Colombia.

METHODS

We conducted an ecological study between 2017 and 2019 to compare before and after obstetric emergency care through telemedicine from a secondary care center (Hospital Francisco de Paula Santander-HFPS) to the referral center (Fundación Valle del Lili-FVL). The intervention included verification visits to determine the installed capacity of care, a concerted improvement plan, and on-site educational training modules in obstetric and perinatal care.

RESULTS

There were 102 and 148 patients treated before and after telemedicine implementation respectively. Clinical indicators after model implementation showed a reduction in perinatal mortality of 29%. In addition, a reduction in the need for transfusion of blood products due to postpartum hemorrhage was observed as well as the rate of eclampsia.

CONCLUSIONS

Implementing a model based on telehealth and education between secondary and tertiary care centers allowed the strengthening of the security of care in obstetric emergencies and had a positive effect on perinatal mortality.

Teleconsultation for outpatient care of patients during the Covid-19 pandemic at a University Hospital in Colombia

BACKGROUND

During the COVID 19 pandemic, direct-to-consumer telehealth (DTC) services allowed patients real-time virtual access to healthcare providers, especially those with an established relationship. In Colombia, this care modality was implemented between 2019 and 2020, under national considerations, it was implemented for outpatient care in a highly complex university hospital in Cali, Colombia.

METHODS

A descriptive study with prospective information collection was used to describe the implementation of the outpatient teleconsultation care model for patients. We constructed the clinical and process indicators with which we evaluated the model.

FINDINGS

A total of 56,560 patients from our institution were treated by virtual outpatient consultation during the first nine months of the health emergency declared by COVID 19 in Colombia. The strategy made it possible to achieve coverage more significant than 100% in Cali and the departments of Colombia. Attention by teleconsultation was 19% of the total ambulatory care. The effectiveness in carrying out scheduled teleconsultations had an overall result of 91.5%. The accessibility results demonstrated the need to strengthen connectivity and accessibility to payments and strengthen technology adoption in the institution, health personnel, and patients.

INTERPRETATION

Implementing an outpatient teleconsultation model allowed the continuity of the management with comprehensive coverage nationwide from a highly complex hospital in southwestern Colombia. The indicators' analysis should help strengthen the policies of access to telemedicine, especially with the consequences of the pandemic in low- and middle-income countries. Latin American evidence is necessary to establish the safety profile of telemedicine and the costs associated with the provision.

Resource use decrease after implementation of care bundles for treatment of postpartum hemorrhage

OBJECTIVE

To evaluate whether the implementation of care bundles has an impact on resource utilization in the care of patients with postpartum hemorrhage (PPH).

METHODS

Retrospective, cross-sectional, observational study of 404 patients with stage II or greater PPH. Periods 2011-2014 and 2015-2017, before and after the introduction of care bundles, were compared. Billing reports were analyzed, and all services provided to treat these events were extracted. Use of resources within the two periods was computed.

RESULTS

The amount billed per episode decreased 18.66% from the first to the second period. Most PPH cases used fewer resources after introduction of care bundles. The greatest reduction was in the use of medications, with a decrease of charges by 56.3%. Diagnostic procedure charges decreased by 47.6% and consultation charges decreased by (37.7%).

CONCLUSIONS

The use of PPH care bundles may be associated with lower resource use and fewer interventions.

Maternal sepsis

Maternal sepsis is "a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion," with the potential to save millions of lives if a proper approximation is made. Undetected or poorly managed maternal infections can lead to sepsis, death, or disability for the mother, and an increased likelihood of early neonatal infection and other adverse outcomes. Physiological, immunologic, and mechanical changes that occur in pregnancy make pregnant women more susceptible to infections than nonpregnant women and may obscure signs and symptoms of infection and sepsis, resulting in a delay in the recognition and treatment of sepsis. Prioritization of the creation and validation of tools that allow the development of clear and standardized diagnostic criteria of maternal sepsis and septic shock, according to the changes inherent to pregnancy, correspond to highly effective strategies to reduce the impact of these conditions on maternal health worldwide. After an adequate diagnostic approach, the next goal is achieving stabilization, trying to stop the progression from sepsis to septic shock, and improving tissue perfusion to limit cell dysfunction. Management protocol implementation during the first hour of treatment will be the most important determinant for the reduction of maternal mortality associated with sepsis and septic shock.

Quiloperitoneo espontáneo en el embarazo

Introducción. El quiloperitoneo consiste en la presencia de fluido linfático en la cavidad intraabdominal, complicación poco descrita en el embarazo y cuyas repercusiones no están bien establecidas. Reporte de caso. Se presenta el caso de una mujer gestante con embarazo de 36,5 semanas, sin comorbilidades, hospitalizada por presentar cifras tensionales elevadas asociadas a síntomas de encefalopatía hipertensiva y bradicardia fetal sostenida; se le practicó una cesárea urgente en la cual se evidenció corioperitoneo incidental. La tomografía computarizada abdominal de control no demostró alteraciones. Discusión. Se descartaron las principales causas del quiloperitoneo, las cuales son neoplasia maligna y trauma. Se consideró que se trataba de un quiloperitoneo espontáneo posiblemente relacionado con la congestión pélvica propia del embarazo, por vasodilatación secundaria al influjo hormonal, aumento de la presión intraabdominal y contribución del volumen ascítico por la preeclampsia, que genera ruptura traumática de los vasos linfáticos. Conclusión. La ascitis quilosa es una entidad poco frecuente que puede verse asociada con el embarazo. Es fundamental el criterio acertado del ginecoobstetra para determinar tempranamente la etiología.

Implementation and Usefulness of Telemedicine During the COVID-19 Pandemic: A Scoping Review

OBJECTIVES

Identify and summarize the available literature on the acceleration in the use of telemedicine in the midst of the COVID-19 pandemic, with an aim to provide justification and guidance for its implementation to overcome the limitations associated with the pandemic worldwide.

METHODS

We conducted a scoping review through different search strategies in MEDLINE and Google Scholar to identify the available literature reporting data on implementation and usefulness of various modalities of telemedicine during the current pandemic. We summarized the included studies according to field and mode of implementation in a narrative way.

RESULTS

We included 45 studies that fulfilled selection criteria. About 38% of the studies were conducted in the United States of America (USA), followed by 15.5% in India and 15.5% in China. Most studies (73%) were cross-sectional studies based on historical records. All publications were written in English with the exception of 1 studied published in Spanish. The majority of reports focused on use of telemedicine for outpatient care, followed by in-hospital care.

CONCLUSION

The COVID-19 pandemic has promoted the use of telemedicine, a tool that has transformed the provision of medical services. Several modes of implementation are useful to overcome difficulties for patient care during the pandemic. Its benefits are specific to different fields of medical practice. Such benefits, along with the guidance and reported experiences should invite health systems to work for an effective and comprehensive implementation of telemedicine in various fields.

Comparison of two identification and susceptibility test kits for Ureaplasma spp and Mycoplasma hominis in amniotic fluid of patients at high risk for intra-amniotic infection

Objective: Ureaplasma urealyticum and Mycoplasma hominis are the most common microorganisms found in the amniotic fluid of patients at risk for preterm delivery. However, culture techniques for genital mycoplasms require special conditions, are barely considered as part of the evaluation of suspected intra-amniotic infection (IAI) and the results are available within 2 and 7 days. The objectives of this study are to validate the use of two commercially available kits (Mycoplasma IES y MYCOFAST^® RevolutioN) for the identification of Ureaplasma spp. and Mycoplasma hominis in amniotic fluid, to compare the results of these kits with those obtained by culture and real-time polymerase chain reaction (qPCR) and to report the antibiotic sensitivity profile of the genital mycoplasms identified.Methods: This is a prospective cohort study including women with singleton and twin gestations between 16 and 36 weeks. Patients were admitted to perform an amniocentesis due to pregnancy complications considered at high risk for IAI (e.g. preterm labor with intact membranes, preterm prelabour rupture of membranes, short cervix, etc.), treatment of polyhydramnios, and for the assessment of fetal death and fever without a focus.Results: Overall, 93 patients underwent amniocentesis and 63 had results available for all tests. The prevalence of a positive culture was 6% (4/63). There were four cases of Ureaplasma spp. and none of Mycoplasma hominis. The qPCR identified one case as Ureaplasma spp., one case as Ureaplasma parvum and two cases as Ureaplasma urealyticum. For all tests, the diagnostic performance was as follows: sensitivity 100% [95% CI (39.8-100%)], specificity 100% [95% CI (93.9-100%)], positive predictive value 100% [95% CI (39.8-100%)] and negative predictive value 100% [95% CI (93.9-100%)]. In this cohort, Ureaplasma spp. showed low resistance to erythromycin, but a high resistance to clindamycin and clarithromycin that may change according to the antibiotic concentration.Conclusions: To our knowledge, this is the first study that validates the use of the Mycoplasma IES and MYCOFAST^® RevolutioN kits for the identification of genital mycoplasmas in amniotic fluid. The results of these kits are mostly available within 24 hours, have an excellent correlation with those from broth cultures and qPCR and characterize the antibiotic sensitivity profile of the genital mycoplasms identified, providing an opportunity for specific treatment in cases of IAI. Further validation studies in other populations are needed.

Comprehensive treatment in severe dengue during preterm and term labor: could tocolysis be useful?

Objective: There is lack of data on the management of severe dengue infection during labor. The objective of this study was to describe our experience in the management of preterm and term labor of pregnant patients with severe dengue infection and thrombocytopenia.Materials and methods: We describe patients with dengue infection confirmed by dengue serology or NS1 antigen in Cali, Colombia. All of the patients had warning or severity signs for dengue and initiated labor, either term or preterm, during their hospital stay. All had thrombocytopenia at the moment labor started. Therefore, we treated them with support management, including intravenous fluids and a tocolytic agent (either atosiban, magnesium sulfate or nifedipine). Tocolytics aimed to stop contractions until platelets were in a safe range previous to delivery. Platelets transfusions were performed if the count was less than 10,000 cells/ml and active bleeding was present. The primary outcome we evaluated was postpartum hemorrhage (defined as a loss of >500 ml following a vaginal delivery or >1000 ml after cesarean section) or maternal and neonatal morbidity and mortality.Results: We present a total of six pregnant women. The median platelet count 24 h previous to delivery was 94,000 cells/ml and after tocolysis was 132,500 cells/ml. Two patients suffered postpartum hemorrhage despite the management. Only one woman required platelet transfusion. No maternal or newborn mortality were present. Three patients were diagnosed with preeclampsia. Four patients had delivery via cesarean section. Five out of six newborns required hospitalization, three of them due to neonatal respiratory distress syndrome.Conclusion: Comprehensive treatment including fluids resuscitation and uterine inhibition in pregnant women with severe dengue in preterm or term labor could be useful. More clinical studies are required to evaluate the benefit of this intervention in tropical countries.Brief rationale: We present an original research article and literature review entitled "Comprehensive treatment in severe dengue during preterm and term labor: could tocolysis be useful?". Our article describes the clinical manifestation, laboratory findings, complications and management provided to a group of six patients that presented to the hospital with acute dengue virus infection and initiated labor while viremic and thrombocytopenic in this study.In the present study, we found that most of our patients (5 out of 6), presented with signs of severe dengue fever and all of the patients had warning signs. In this population, we decided to provide support treatment and tocolytic agents to these patients with the aim of delaying labor to allow platelet count to rise, thus reducing the odds of hemorrhagic complications. We concluded that although tocolysis is not regularly used in patients with dengue fever, our results suggest that our protocol could benefit pregnant patients with thrombocytopenia due to dengue; however, prospective studies which determine the safety and effectiveness of our intervention are needed.

Placenta accreta: importance of a multidisciplinary approach in the Colombian hospital setting

Introduction: The management of patients with placenta accreta (PA) poses a challenge to health services. Although it may lead to devastating complications, its low incidence limits the development of expertize in all obstetric centers. We evaluated the results obtained from a multidisciplinary approach in patients with PA in a Latin American hospital.Methods: The study included patients with prenatal suspicion or intraoperative diagnosis of PA, before and after initiating a set of interdisciplinary and institutional interventions, with the aim of achieving better outcomes.Results: From December 2011 to December 2017, 62 patients with prenatally or intraoperatively suspected PA underwent surgery. The first 30 women (Group A), admitted until April 2016 and before any changes in the management protocol, had a longer hospital stay and surgery time, higher newborn hospitalization, and greater use of general anesthesia, compared to the 20 patients from Group B, who were admitted during the last 20 months of the observation period. A total of 12 women with late and intraoperative diagnosis, under no institutional protocol, showed greater blood loss and more frequent red blood cell transfusions.Conclusions: The expertize of the multidisciplinary team responsible for managing women with PA is associated with better clinical outcomes.

Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in the Fundación Valle Del Lili, Cali, Colombia

BACKGROUND

The aim of this case series is to describe the experience of using the non-pneumatic anti-shock garment (NASG) in the management of severe Postpartum hemorrhage (PPH) and shock, and the value of implementing this concept in high-complexity obstetric hospitals.

METHODS

Descriptive case series of 77 women that received NASG in the management of PPH with severe hypovolemic shock from June 2014 to December 2015. Vital signs, shock index (SI), the lactic acid value and the base deficit were compared before and after NASG application.

RESULTS

Fifty-six (77%) women had an SI > 1.1 at the time shock management was initiated; 96% had uterine atony. All women received standard does of uterotonics. The average time between the birth and NASG applications was 20 min. Forty-eight percent of women recovered haemodynamic variables in the first hour and 100% within the first 6 h; 100% had a SI < 1.0 in the first hour. The NASG was not removed until definitive control of bleeding was achieved, with an average time of use of 24 h. There were no mortalities.

CONCLUSIONS

In this case series of women in severe shock, the NASG was an effective management device for the control of severe hypovolemic shock. It should be considered a first-line option for shock management.